This thesis is an exploratory case study that investigates a 'successful' pupil referral unit (PRU) for key stage 3 secondary school pupils located in the semi-rural southwest of England. The achievement of the PRU was externally acknowledged by the Office for Standards in Education (Ofsted) with a recently reported overall grade of 1 or ‘Outstanding’. This exploratory study took a social constructionist approach and was informed by the methodology of illuminative evaluation. This study explored the stories and experiences of pupils and staff using interviews, a focus group and video diaries for the pupils. The analysis of these data was from a socio-cultural theoretical perspective. The research data suggested that success was in a state of flux for all in the PRU. For pupils there were personal transformations in their attitudes, behaviours and values. Pupils’ social and emotional capital was increased by the ‘deep relationships’ that developed between pupils and staff. The innovative approach to the curriculum allowed pupils to engage positively with education and featured lessons that were routinely based upon experiential learning. This included weekly outdoor learning lessons which provided a rich context for informal learning to take place alongside the formal objectives. Leadership and management appeared to be the keystone of the PRU success. There was a clear well founded educational philosophy that was successfully articulated through the operational systems of the PRU. All of these parts contributed to the holistic success of the PRU. Findings from this case study are not generalisable due to its specificity to one particular setting and small number of participants. However, ‘naturalistic generalisations’ may be arrived at by the reader. For example, the reader may be able to apply some aspects of good practice, such as developing deep relationships, to their own context when working with those pupils who are, or have the potential to be, disaffected.

The cost of health care services is rising and the number of patients requesting overseas treatment from the Kuwait Government continues to increase; this is becoming an unsustainable financial burden. A telemedicine system has the potential to support the Kuwaiti health system to provide medical consultations from global medical centres, and thereby reduce the number of Kuwaiti patients being sent abroad for treatment, and so reduce costs. This research investigates the readiness of the key stakeholders in regard to adoption of telemedicine systems in the Kuwaiti healthcare system. This is achieved by assessing the readiness of individuals (physicians and patients), the organisation (policy makers) and the technical infrastructure (IT managers). Moreover, the lack of research on this topic, particularly in the Arabian Gulf Region, was the reason behind carrying out this study. An in-depth study was conducted by using a quantitative and qualitative approach. A questionnaire was used to explore the attitudes of specialised physicians and patients by obtaining their opinions based on specific criteria. Next, semi-structured interviews were conducted: (1) with IT managers to assess the technical infrastructure of the health system; and (2) with policy makers to assess the organisation in regard to its readiness towards telemedicine adoption. The study shows that the overseas referral patients are ready to use telemedicine systems, as a consequence of their need to receive medical consultations from global experts. However, they expressed some concerns, such as privacy and confidentiality of their data. The specialised physicians also showed readiness towards adoption of telemedicine in the Kuwaiti health system, and their responses indicated that they are willing to use such systems. However, the findings of the interviews reveal that the current technical infrastructure for ICT in the Kuwaiti healthcare system is not ready for telemedicine adoption and there are needs to be change in the way management is organized in order to improve and enhance trust among departments. The qualitative approach identified factors that would inhibit and hinder the adoption of telemedicine in Kuwait, as well as the supportive factors in the organisation. Using the results, a strategy was developed to demonstrate how the Kuwaiti health system could be made ready to receive a telemedicine system, together with policies for the use of telemedicine systems by overseas referral patients. A comparison with Jordan and Syria shows that the Kuwaiti healthcare system is more ready to adopt a telemedicine system with respect to the individuals, technical infrastructure and governmental support. Finally, an economic analysis was performed in order to investigate the cost effectiveness of the proposed system.

This study was designed to ascertain whether group achievement test data can determine special education referral accuracy. One hundred eighty-nine special education referrals from four school districts in Texas were examined. The demographics were limited to group achievement test data: grade equivalents and percentiles in the subject areas of reading, spelling, language arts, and mathematics. Also examined were referral and eligibility outcomes to special education.

Background and Purpose A debate over the practice of physician self-referral has been ongoing in health care since the 1980s. At issue is the practice of physicians who refer patients to facilities in which they share a financial interest, a phenomenon known as referral for profit. Physician investment or ownership interest in ancillary (e.g., physical therapy) services has been shown to have an impact on utilization rates, costs, access to care, and quality of care. What has not been identified in previous research is the influence of physicians‘ selective referral on competing clinics, particularly the hospital-based outpatient centers that share their health care markets. The purpose of this research was to examine the relationship between the emergence of orthopaedic physician owned physical therapy services (POPTS) and changes in physical therapy referrals made to two groups of not-for-profit, hospital-based outpatient physical therapy (OPPT) centers in one health care market. Methods This study examined the referrals made by orthopaedic physicians to two large hospital systems in the Orlando, Florida, outpatient physical therapy market between 1999 and 2007. This study was conducted using existing proprietary databases maintained by the Orlando Regional Healthcare System (ORHS) and Florida Hospital System (FHS), as well as phone surveys conducted by the primary investigator. Information regarding the orthopaedic physicians‘ ownership status and the patients‘ payer types was combined into analyses to determine if physician status was related to the number of physical therapy patients from each payer type referred, or the number of total referrals made to the hospital-based outpatient physical therapy facilities. Comparisons were made between physicians who became owners of physical therapy services during the study period and physicians who never became owners of physical therapy services. Mixed Linear Models (MLM) were used to test for the effects of physician ownership and the combined influence of physician ownership and payer type on referrals for OPPT. Point estimates and 95% confidence intervals were calculated for the mean differences between Group 1 and Group 3 physicians for changes in OPPT referrals over time. The analyses were conducted first with samples of physicians who met a minimum criterion of ten referrals within the first year of data included in the data sets. Use of this criterion resulted in a small pool of physicians who qualified for inclusion in the testing. Data were compared between years 1 and 5 and then between years 1 and 2 versus 4 and 5. The criterion for physicians‘ inclusion was revised for post hoc analysis in an attempt to increase the sample size. All of the statistical tests were repeated in post hoc with the larger samples of physicians who met the minimum criterion of an average of ten referrals per year for years 1 and 2 rather than just the referral count for year 1. Results Overall, there was no statistically significant change in the total referrals as a result of a change in physicians‘ ownership status. Tests for the influence of payer type, physician group, and ownership status on referrals also revealed no significant differences between the two physician groups. Point estimates of the differences between Group 1 and Group 3 for changes in mean referrals supported the hypothesized relationships between physicians‘ ownership status and total referrals, referrals of commercially insured patients, and referrals of underinsured patients; however, the 95% confidence intervals for the point estimates were consistent with the non-significant MLM results. The hypothesized relationship between POPTS and referrals of Medicare patients was not supported in any of the analyses. In post hoc testing of the combined influence of payer type, physician group, and ownership status on referrals, a three-way interaction between physician group, payer type, and status was found (p=0.034, α<0.05). Including a larger sample size in the post hoc analyses led to outcomes that were different than those seen in the initial statistical tests. Conclusion This research outlines a novel approach to analyzing the influence of physician ownership and payer type on referral behaviors. The findings suggest that physicians‘ ownership of physical therapy services was not a predictor of their referrals to hospital-based OPPT services. Specifically, there was no significant effect of physician ownership of OPPT services on the total volume of referrals made to two hospital-systems‘ OPPT clinics. There also was no significant relationship between physician ownership, payer type, and referrals made to the hospital-based clinics. The theory predicting that POPTS physicians would work to eliminate market competition by reducing referral volumes and retaining patients with more lucrative reimbursement for their own practices was not supported. However, post hoc analysis with a larger sample size provided some evidence that a larger sample may have revealed the hypothesized relationships between physician ownership, payer type, and referrals for OPPT. Future research utilizing larger samples and data tracking physicians‘ OPPT referrals from their origins to their final dispositions are needed to clarify the relationships between physicians‘ ownership of OPPT services and the referrals they make for those services.

BackgroundWithin dentistry, a limited body of literature exists regarding the referral relationships between general practitioners (GPs) and specialists. The purpose of this study was to investigate the referral relationship between GPs and periodontists within the state of Virginia. MethodsA survey focused on the demographic variables in the referral relationship between GPs and periodontists was developed. The survey was mailed to 800 dentists throughout the state of Virginia. Descriptive statistics was completed along with multivariate logistic regression analysis comparing the responses with the number of patients referred per month to a periodontist. ResultsFemale respondents were more likely to refer three or more patients per month to a periodontist than a male respondent (pConclusion This study indicates that four demographic variables have a statistical influence on the number of referrals per month from a GP to a periodontist. These variables are: female gender, practicing with one other dentist, employing two or more hygienists, and being greater than five miles away from the nearest periodontist.

Nesta dissertação, temos como escopo estudar, através das notícias, as características discursivas do jornal gratuito Publimetro (também conhecido como Metro). Nosso corpus abarca notícias de maio de 2008 a julho de 2011. Nosso principal objetivo está em analisar as notícias referentes a minorias sociais. Para isso, utilizaremos o Processo de Referenciação sob a perspectiva da Análise Crítica do Discurso. Apresentamos numa perspectiva histórica, os Gêneros Discursivos e o Jornalismo com o intuito de contextualizar o corpus e situar o leitor, fazendo-se dessa maneira uma análise sobre o gênero notícia e, por fim, a contextualização desse gênero no jornal em foco. Em seguida, discutimos o Processo de Referenciação sob a perspectiva da Análise Crítica do Discurso, que associa a perspectiva sociológica e política sobre o jornalismo como discurso social e a atenção particular à linguagem e às suas escolhas de realização em atos de comunicação. E, finalmente, apresentamos a análise do corpus, com destaque para as escolhas lexicais utilizadas pelo enunciador e que revelam diretamente a sua opinião. Tais análises feitas nos permitem depreender que as expressões nominais remissivas funcionam como uma espinha dorsal do texto, que permite ao leitor/ouvinte construir, com base na maneira pela qual se encadeiam e remetem umas às outras, um script que irá guiá-lo para determinados sentidos contidos no texto e, consequentemente, para as leituras possíveis que, a partir dele, se arrojam. (cf. KOCH, 2005, p.46). Além disso, concluímos também que nem sempre o poder é exercido através de atos obviamente abusivos praticados por membros de um grupo dominante; antes, pode estar incorporado no grande número de ações consideradas rotineiras, como é tipicamente o caso de muitas formas de sexismo e de racismos cotidianos. / In this dissertation, we take as scope to study, through the news, the discursive characteristics of the free newspaper Publimetro (also known as Metro). Our corpus covers news from May 2008 to July 2011. Our main goal is to analyse the news referin to the social minorities. Therefore, we will use the Process of Referral under the perspective of Analytical Criticism of Speech. We present a historical perspective, the genres and journalism in order to contextualize the corpus and place the reader, thus making it a gender analysis of the news and, finally, the contextualization of this kind in the newspaper in focus. Next, we discuss the Process of Referral from the perspective of Analytical Criticism of Speech, which combines the political and sociological perspective on journalism as a social discourse and attention to language choices and their realization in acts of communication. And finally, we present the analysis of the corpus, with emphasis on the word choice used by the enunciator and reveal your opinion directly. Such analyzes allow us to conclude that the nominal expressions remissive work as a backbone of the text, which allows the reader / listener to build, based on the manner in which are connected and relate to each other, a \"script\" that will guide you for certain directions contained in the text and thus to possible readings that from him, flung themselves. (cf. KOCH, 2005, p.46). Moreover, we conclude also that not all the power is exercised through obviously abusive acts committed by members of a dominant group, but rather can be embedded in many actions considered routine, as is typically the case with many forms of sexism and everyday racism.

by Chong Yu Hoi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1995. / Includes bibliographical references (leaves 166-172). / Chapter 1. --- Introduction --- p.1 / Chapter 2. --- Background --- p.5 / Chapter 2.1. --- Evolution of Primary Health Care in Last TwoDecades 226}0ؤ An Overview --- p.5 / Chapter 2.2. --- Role of Primary Health Care --- p.11 / Chapter 2.3. --- Significance of Referral Between Primary and Secondary Health Care --- p.12 / Chapter 2.4. --- Attributes of Referral --- p.14 / Chapter 2.4.1. --- Referral Rate --- p.14 / Chapter 2.4.2. --- Referral Pattern --- p.19 / Chapter 2.4.3. --- Reason of Referral --- p.20 / Chapter 2.4.4. --- Appropriateness of Referral --- p.24 / Chapter 2.4.5. --- Referral Letter --- p.30 / Chapter 3. --- Situation in Hong Kong --- p.34 / Chapter 3.1. --- Health of the Society --- p.34 / Chapter 3.2. --- History of GOPC Service in Hong Kong --- p.35 / Chapter 3.3. --- Present Situation of GOPC Services --- p.37 / Chapter 3.4. --- Previous Surveys on Private Practice in Hong Kong --- p.38 / Chapter 3.5. --- Previous Surveys on GOPC Services in Hong Kong --- p.39 / Chapter 3.6. --- A Review of Data from 12 GOPCs --- p.44 / Chapter 4. --- The Study: Objectives and Method --- p.48 / Chapter 4.1. --- Objectives --- p.48 / Chapter 4.2. --- Materials & Method - The Framework of the Study --- p.51 / Chapter 4.3. --- Phase One --- p.52 / Chapter 4.3.1. --- Study Population --- p.53 / Chapter 4.3.2. --- Sampling Method --- p.53 / Chapter 4.3.3. --- Survey Method --- p.53 / Chapter 4.3.4. --- Data Analysis --- p.54 / Chapter 4.4. --- Phase Two --- p.55 / Chapter 4.4.1. --- Study population --- p.56 / Chapter 4.4.2. --- Sampling Method --- p.57 / Chapter 4.4.3. --- Survey Method --- p.57 / Chapter 4.4.4. --- Data Analysis --- p.58 / Chapter 4.5. --- Phase Three --- p.59 / Chapter 4.5.1. --- Study Population --- p.59 / Chapter 4.5.2. --- Sampling Method --- p.60 / Chapter 4.5.3. --- Survey Method --- p.60 / Chapter 4.5.4. --- Data Analysis --- p.60 / Chapter 5. --- Study Result: Phase One --- p.62 / Chapter 5.1. --- The Response Rate --- p.62 / Chapter 5.2. --- Profile of Patients --- p.63 / Chapter 5.3. --- Referral Rate --- p.64 / Chapter 5.3.1. --- The Spectrum In Hong Kong --- p.64 / Chapter 5.3.2. --- Relationship with Individual GOPC --- p.65 / Chapter 5.3.3. --- Relationship with Practice Size --- p.66 / Chapter 5.3.4. --- Relationship with the Day of the Week --- p.67 / Chapter 5.3.5. --- Relationship with Workload of the Day --- p.69 / Chapter 5.3.6. --- Relationship with Workload of Doctor --- p.70 / Chapter 5.3.7. --- Relationship with Basic Medical Training --- p.72 / Chapter 5.3.8. --- Relationship with Year of Experience --- p.73 / Chapter 5.3.9. --- Relationship with Higher Qualification --- p.73 / Chapter 5.4. --- Referral Pattern --- p.74 / Chapter 5.5. --- Reason of Referral --- p.75 / Chapter 5.6. --- Prescription Rate --- p.77 / Chapter 5.7. --- Investigation Rate --- p.78 / Chapter 5.8. --- Duration of Disease before Referral --- p.78 / Chapter 5.9. --- Number of GOPC consultation before Referral --- p.79 / Chapter 6. --- Study Result: Phase Two --- p.82 / Chapter 6.1. --- Response Rate --- p.82 / Chapter 6.2. --- Background of the Referral --- p.83 / Chapter 6.2.1. --- GOPCs of Referral --- p.83 / Chapter 6.2.2. --- Waiting Time for SOPC Appointment --- p.85 / Chapter 6.2.3. --- The patients --- p.86 / Chapter 6.3. --- Present Complaint --- p.87 / Chapter 6.3.1. --- Duration of Disease before Referral --- p.87 / Chapter 6.3.2. --- Number of GOPC Consultation before Referral --- p.89 / Chapter 6.4. --- Assessment of Referral --- p.90 / Chapter 6.4.1. --- Management of Referring Doctor --- p.90 / Chapter 6.5. --- Referrals with Inappropriate Necessity --- p.91 / Chapter 6.5.1. --- The Patients --- p.91 / Chapter 6.5.2. --- Referring GOPCs --- p.93 / Chapter 6.5.3. --- The Specialties --- p.94 / Chapter 6.5.4. --- "Diagnosis, Investigation & Treatment" --- p.95 / Chapter 6.5.5. --- Timing of Referral --- p.97 / Chapter 6.5.6. --- Duration of Present Attack --- p.97 / Chapter 6.5.7. --- Outcome of Referral --- p.97 / Chapter 6.6. --- Referrals with Inappropriate Timing --- p.98 / Chapter 6.6.1. --- The Patients --- p.98 / Chapter 6.6.2. --- The Referring GOPCs --- p.98 / Chapter 6.6.3. --- The Specialties --- p.100 / Chapter 6.6.4. --- Necessity of Referral --- p.101 / Chapter 6.6.5. --- Number of GOPC Visit before Referral --- p.101 / Chapter 6.6.6. --- Number of GOPC Visit with Specialty --- p.102 / Chapter 6.6.7. --- Duration of Disease --- p.103 / Chapter 6.6.8. --- Duration of Disease with Specialty --- p.104 / Chapter 6.6.9. --- "The Diagnosis, Number of GOPC Visit and Duration of Illness" --- p.105 / Chapter 6.6.10. --- Investigation & Treatment Prescribed --- p.107 / Chapter 6.6.11. --- Prognosis of the Referred Cases --- p.109 / Chapter 6.7. --- Referrals with Inappropriate Investigation --- p.110 / Chapter 6.7.1. --- The Patients --- p.110 / Chapter 6.7.2. --- The Referring GOPCs --- p.110 / Chapter 6.7.3. --- The Specialties --- p.112 / Chapter 6.7.4. --- The Diagnosis & Investigation --- p.113 / Chapter 6.7.5. --- Prognosis of Referral --- p.115 / Chapter 6.8. --- Referrals with Inappropriate Treatment --- p.115 / Chapter 6.8.1. --- The Patients --- p.115 / Chapter 6.8.2. --- Referring GOPC --- p.115 / Chapter 6.8.3. --- The Specialties --- p.117 / Chapter 6.8.4. --- The Diagnosis & Treatment --- p.118 / Chapter 6.8.5. --- Prognosis of the Referred Cases --- p.119 / Chapter 6.9. --- Assessment of the Referral Letter --- p.120 / Chapter 7. --- Study Result: Phase Three --- p.122 / Chapter 7.1. --- The Response Rate --- p.122 / Chapter 7.1.1. --- The GOPC Doctors --- p.122 / Chapter 7.1.2. --- The Specialists --- p.123 / Chapter 7.2. --- Profile of GOPC Doctors --- p.123 / Chapter 7.2.1. --- Years of Clinical Practice --- p.123 / Chapter 7.2.2. --- Qualification Obtained --- p.124 / Chapter 7.3. --- Profile of Specialists --- p.125 / Chapter 7.3.1. --- Years of Clinical Practice --- p.125 / Chapter 7.3.2. --- Qualification Obtained --- p.126 / Chapter 7.4. --- Workload of the Participating Doctors --- p.126 / Chapter 7.4.1. --- Number of outpatient Seen by GOPC Doctors --- p.126 / Chapter 7.4.2. --- Number of outpatient Seen by Specialists --- p.126 / Chapter 7.5. --- Referrals from GOPCs to Specialist Clinics --- p.127 / Chapter 7.5.1. --- Percentage of GOPC Cases Referred to Specialist Clinics --- p.127 / Chapter 7.5.2. --- Percentage of Specialist Cases Referred from GOPCs --- p.127 / Chapter 7.6. --- Communication between GOPC and Specialist Clinic --- p.128 / Chapter 7.6.1. --- Opinion of GOPC Doctors on Referral Letters --- p.128 / Chapter 7.6.2. --- Opinion of GOPC Doctors on Feedback from Specialists --- p.130 / Chapter 7.6.3. --- Opinion of Specialist on Referral Letters --- p.131 / Chapter 7.6.4. --- Opinion of Specialists on Their Feedback --- p.135 / Chapter 7.7. --- The Form of Feedback from Specialists --- p.136 / Chapter 7.8. --- Suggestions on Improving the Communication --- p.137 / Chapter 7.9. --- In Service Training for GOPC Doctors --- p.138 / Chapter 8 --- _ Discussion and Recommendation --- p.141 / Chapter 8.1. --- Limitations and Comments --- p.141 / Chapter 8.1.1. --- Representativeness of The Sample --- p.141 / Chapter 8.1.2. --- Response Rate --- p.141 / Chapter 8.1.3. --- Size of The Sample --- p.142 / Chapter 8.1.4. --- Short Duration of the Study --- p.142 / Chapter 8.1.5. --- Discontinuity of Phase One and Phase Two --- p.143 / Chapter 8.2. --- Discussion --- p.144 / Chapter 8.2.1. --- Referral Rate in Hong Kong --- p.145 / Chapter 8.2.2. --- Referral Pattern and Reason of Referral --- p.147 / Chapter 8.2.3. --- Appropriateness of Referrals --- p.149 / Chapter 8.2.4. --- Communication between GOPCs & SOPCs --- p.149 / Chapter 8.2.5. --- In Service Training for GOPC Doctors --- p.150 / Chapter 8.2.6. --- Waiting Time for SOPCs Appointment --- p.151 / Chapter 8.2.7. --- Prescription Rate --- p.152 / Chapter 8.2.8. --- Common Investigations Requested by Specialists --- p.153 / Chapter 8.2.9. --- Factors Associated with Referral Rates --- p.155 / Chapter 8.2.10. --- Factors Associated with Appropriateness of Referrals --- p.157 / Chapter 8.2.11. --- Factors Associated with Timing of Referrals --- p.158 / Chapter 8.3. --- Recommendation --- p.161 / Chapter 8.3.1. --- Further Study in Private Sector --- p.161 / Chapter 8.3.2. --- Further Study in Other Regions --- p.161 / Chapter 8.3.3. --- Further Study on the Appropriateness of those Non-referrals --- p.161 / Chapter 8.3.4. --- Improve Record in Specialist Clinics --- p.162 / Chapter 8.3.5. --- Upgrade of GOPC Drug Formulary --- p.162 / Chapter 8.3.6. --- Standard Referral & Feedback Form --- p.163 / Chapter 8.3.7. --- Shared Care Program between SOPCs & GOPCs --- p.163 / Chapter 8.3.8. --- Medical Record System in GOPCs --- p.163 / Chapter 8.3.9. --- Further Training for GOPC Doctors --- p.164 / Chapter 8.3.10. --- Principal Medical Officer for GOPC Service --- p.164 / Chapter 9. --- Reference --- p.166 / Chapter 10. --- Appendix --- p.173

by Lam Ho Cheung, Andrew. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1993. / Includes bibliographical references (leaves 1-5 (3rd gp.)). / ABSTRACT --- p.I1-3 / ACKNOWLEDGEMENTS --- p.II / TABLE OF CONTENTS --- p.III1-2 / Chapter CHAPTER ONE - --- INTRODUCTION / Chapter 1.1 --- The Problem --- p.1 / Chapter 1.2 --- The purpose of the thesis --- p.5 / Chapter CHAPTER TWO - --- PSYCHIATRIC OUTPATIENT SERVICE PROVISION / Chapter 2.1 --- Provision of psychiatric outpatient provision --- p.6 / Chapter 2.2 --- The problem of pattern of consultation --- p.13 / Chapter CHAPTER THREE- --- OBJECTIVES AND HYPOTHESIS SETTING / Chapter 3.1 --- Objectives --- p.30 / Chapter 3.2 --- Definition of essential terms --- p.30 / Chapter 3.3 --- Hypothesis setting --- p.32 / Chapter CHAPTER FOUR - --- METHOD / Chapter 4.1 --- Research design and Data collection method --- p.36 / Chapter 4.2 --- Recording schedule design --- p.37 / Chapter 4.3 --- Setting --- p.39 / Chapter 4.4 --- Subjects --- p.40 / Chapter 4.5 --- Data Collection and Processing --- p.40 / Chapter 4.6 --- Data analysis --- p.43 / Chapter CHAPTER FIVE - --- DESCRIPTIVE FINDINGS / Chapter 5.1 --- The overall pattern of consultations --- p.45 / Chapter 5.2 --- Diagnostic group of sex and age group --- p.53 / Chapter CHAPTER SIX - --- FACTORS ASSOCIATED WITH DROP-OUTS OF PATIENTS / Chapter 6.1 --- Background of the drop-outs and the non-drop-outs group --- p.55 / Chapter 6.2 --- Univariate analysis of relationship between various variables and drop-outs --- p.55 / Chapter 6.3 --- Multiple logistic regression model of relationship between drop-outs and various variables --- p.58 / Chapter CHAPTER SEVEN - --- FACTORS ASSOCIATED WITH PROLONGED & CONTINUED ATTENDANCE / Chapter 7.1 --- Background of the treated & discharged group and prolonged & continued attendance group --- p.62 / Chapter 7.2 --- Univariate analysis of relationship between various variables and prolonged & continued attendance --- p.62 / Chapter 7.3 --- Multiple logistic regression model of relationship between prolonged & continued attendance and various variables --- p.65 / Chapter CHAPTER EIGHT - --- DISCUSSION / Chapter 8.1 --- The overall pattern of consultations --- p.69 / Chapter 8.2 --- Factors associated with the risk of drop-outs --- p.76 / Chapter 8.3 --- Factors associated with the prolonged & continued attendance --- p.80 / Chapter 8.4 --- Implications to service delivery --- p.85 / Chapter 8.5 --- Limitations of this thesis --- p.86 / Chapter CHAPTER NINE - --- CONCLUSION AND RECOMMENDATIONS / Chapter 9.1 --- Conclusion --- p.90 / Chapter 9.2 --- Recommendations --- p.92 / Chapter 9.3 --- Suggestion for future work --- p.93 / BIBLIOGRAPHY / APPENDIX I - TABLE / APPENDIX II- SAMPLE RECORDING SCHEDULE

The overall aim of the thesis is to explore the determinants of General Practitioner (GP) referrals to specialist mental health services, in particular psychological therapy. Paper 1 is intended to contribute to this literature by providing a systematic review of GP and organisational factors identified as impacting on referral in previous research. According to this literature, referral to a mental health specialist was more likely if the GP does not feel that they have the 'capacity to help' and perceives 'time constraints' on how long they can spend with the patient. Referral also appeared more likely if the GP felt they had acceptable 'access to services' and if they had a close 'consultation/liaison' relationship with specialists. The theoretical and clinical implications of these findings are discussed, and gaps in the current literature identified for further research. Paper 2 describes an empirical study aimed at exploring the determinants of GP referral for psychological interventions within Primary Care Mental Health Services (PCMHS). 132 GPs completed questionnaires, including demographic information, attitudes towards mental health and its treatment and responses to short fictional case vignettes indicating their likelihood of referral to the PCMHS. Qualitative results suggested that GPs consider a range of factors in their referral decisions, including patient preference, severity of the problem, access to services and the effectiveness of the service. Alternative options considered included signposting to other services, reviewing, medication and providing advice and support. Quantitative results suggested that younger GPs reported a higher likelihood of referral, and were more likely to refer in line with guidelines. Psychological factors were not associated with referral likelihood or referral in agreement with guidelines. In line with previous research on clinician behaviour, findings of papers 1 and 2 are considered primarily in the context of the Theory of Planned Behaviour, and the utility of this model in predicting referral behaviour is evaluated throughout. A greater understanding of predictors of referral is thought to be valuable in designing clinician and service level interventions to improve the proportion of those in need who are able to access psychological therapy. Paper 3 provides a critical evaluation of the research process as a whole, including the processes involved in the literature review and empirical study. The strengths and weaknesses of both of these elements are discussed, along with an evaluation of the overall approach taken throughout the thesis. The findings of both studies are integrated and discussed in the context of current policy and proposed changes to healthcare provision. Implications for theory, clinical practice and further research are discussed.

Introdução: Os Centros de Referência (CR) são serviços especializados, parte de um projeto inovador de parceria entre a academia e os gestores do Sistema Único de Saúde (SUS). O principal objetivo de um CR é promover a assistência através de acompanhamento multidisciplinar, facilitando o acesso ao medicamento fornecido pelas Secretarias Estaduais de Saúde (SES). Objetivos: avaliar a efetividade da assistência de pacientes com Mieloma Múltiplo (MM) em um CR no âmbito do SUS (Centro de Referência para Mieloma Múltiplo do Hospital de Clínicas de Porto Alegre [CRMM-HCPA]); comparar a qualidade de vida entre portadores de MM atendidos no CRMM-HCPA e em outros serviços de saúde que não são CR. Metodologia: Foi realizado um estudo prospectivo de 6 meses, com participantes que recebiam a Talidomida pela SES-RS, e eram tratados pelo CRMM-HCPA, em comparação com os que recebiam tratamento em outras instituições, fora de um CR. Foram incluídos 32 participantes da pesquisa, sendo 19 do CRMM-HCPA e 13 participantes de outras instituições. Para análise da efetividade do CRMM-HCPA foi considerado como desfecho principal o tempo, a partir do diagnóstico, em que os participantes da pesquisa levaram para realização do Transplante Autólogo de Células Tronco Hematopoiéticas (TACTH), por ser considerado este a terapia “padrão ouro” para o MM. Para análise deste tempo, foram aplicados questionários específicos do estudo e para análise da qualidade de vida foi aplicado o questionário SF-36. Resultados: Na análise de qualidade de vida encontramos diferença significativa em relação ao item aspecto social (do SF-36), relacionado à realização de atividades sociais (P = 0,02). O tempo (em meses) a partir do diagnóstico até o transplante de medula óssea, em cada grupo, foi medido apenas em participantes da pesquisa com idade \65 anos (n=25), dos quais, nesta análise, 15 eram do HCPA e 10 das outras instituições. Encontramos diferença significativa (P=0,036) em relação ao tempo em que os participantes da pesquisa foram encaminhados para realizarem o transplante autólogo, demonstrando que os do CRMM (HCPA) são encaminhados para o transplante em tempo significativamente inferior (mediana: 9 meses; IIQ: 8,5 a 14,5) do que são atendidos nas demais instituições (mediana: 24 meses; IIQ: 16 a 24). Conclusões: Os participantes do CRMM demonstraram mais facilidade em executar atividades sociais, com menos interferências relacionadas a problemas físicos ou emocionais. O CRMM demonstrou ser uma estratégia de tratamento mais efetiva do que outros serviços de saúde do SUS, que não são CR, uma vez que permitiu uma redução do tempo para a realização do transplante. / Introduction:Within the Brazilian Unified Health System (SUS), Referral Centers (RCs) are care facilities that provide specialized services as part of an innovative partnership project between universities and SUS managers. The main goal of RCs is to promote care through a multidisciplinary approach, facilitating access to medicines supplied by state health departments (SHDs).Objectives:To evaluate the effectiveness of care provided to patients with multiple myeloma (MM) in a RC within SUS (Hospital de Clínicas de Porto Alegre Referral Center for Multiple Myeloma, CRMM-HCPA) and to compare quality of life between patients with MM treated at CRMM-HCPA and other non-RC health care facilities. Methods: A 6-month prospective cohort study was conducted in patients receiving thalidomide from the Rio Grande do Sul SHD (SHD-RS) and treated at CRMM-HCPA, as compared to patients receiving treatment at other non-RC health care facilities. Thirty-two patients were included in the study, 19 from CRMM-HCPA and 13 from other institutions. To analyze the effectiveness of CRMM-HCPA, the main outcome measure was the time from diagnosis to referral for autologous hematopoietic stem cell transplantation (HSCT), as this is considered the gold-standard treatment for MM. Time from diagnosis to referral for autologous HSCT was assessed using questionnaires specifically designed for this study, and quality of life was assessed using the SF-36 questionnaire. Results: On quality of life analysis, there was a significant difference in the “social functioning” domain of the SF-36 questionnaire, which relates to performance of social activities (P=0.02). The time (in months) from diagnosis to referral for autologous HSCT, in each group, was measured only in patients aged \65 years (n=25); of these, 15 were from CRMM-HCPA and 10 from other institutions. In this analysis, there was a significant difference (P=0.036) in time between diagnosis and referral for autologous HSCT, which was significantly shorter for patients treated at CRMM-HCPA (median, 9 months; IQR, 8.5–14.5) than for those treated elsewhere (median, 24 months; IQR, 16–24).Conclusions:Patients treated at CRMM-HCPA demonstrated greater ease in performing social activities, with less interference from physical or emotional problems. CRMM-HCPA offers a more effective treatment strategy as compared with other non-RC health care facilities, as it enabled a reduction in time to transplantation.